Over a year and a half into this pandemic, several countries including Singapore and New Zealand are moving to recalibrate their “zero-COVID-19” strategies, even as many other countries like the Philippines struggle to contain the virus and prevent their health systems and economies from being overwhelmed. It is critical to understand the reasons why “zero-COVID-19” may no longer be feasible, and what practical alternatives there are in terms of “living with COVID-19,” as these may finally start to define the new normal.
Shifting to “Living With COVID-19”
Until recently, Singapore implemented its “zero-COVID-19” strategy through strict border controls, a mask mandate, social distancing, and contact tracing. It recently began a pivot to a “living with COVID-19” strategy, given the mounting economic costs of its restrictions, and its growing confidence thanks to successful mass vaccination. By September, Singapore had already vaccinated over 80 percent of its population, and aims to increase this to 90 percent in short order.
Starting in September, Singapore planned to ease its mobility restrictions so as to provide its economy some more room to recover, notably by allowing dining-in to resume, raising group sizes to five for the fully vaccinated, easing work-from-home rules, and loosening quarantine-free travel for vaccinated travelers. Frequent testing was expected to replace mandatory stay-home rules on arrival, reducing the “chilling effect” of its restrictions on Singapore’s tourism industry. Nevertheless, due to a historic surge in cases early in this recalibration, Singapore officials decided to delay opening the economy and are pursuing even higher vaccination rates. They also approved booster shots for seniors.
Part of the challenge with this shift, particularly for a country that did not see its COVID-19 cases and mortality rise, is to convince the public. The rallying cry in 2020 was to “flatten the COVID-19 curve,” which for some countries meant driving case counts to zero or near zero. For those countries, the public became sensitive to information on the number of cases as the main performance measure. Singapore faces this challenge now as it tries to convince the public that the new focus should be on minimizing hospitalizations and mortality, given that vaccines significantly diminish the risks in these areas but do not guarantee zero infections.
Referring to the calculus of the government’s vaccination strategy, Singapore’s finance minister noted in early October that up to 98 percent of the country’s citizens will likely contract the disease at some point, but he reassured them at the same time that only 2 percent will likely experience severe symptoms and require hospital care.
Re-thinking Herd Immunity
The emerging evidence on vaccination is quite compelling. One study covering 112 counties in the United States (around 147 million total population) found that a 10 percentage point increase in vaccine coverage resulted in a 28 percent decrease in COVID-19 incidence and a 44 percent drop in hospitalization rates. Clinical trials for various vaccines indicated strong effectiveness ranging from 67 percent (Johnson & Johnson) to 70 percent (Oxford AstraZeneca) to 94 percent (Moderna), 95 percent (Pfizer-BioNTech), and 96 percent (Novovax). Real-world conditions, however, include various confounding factors, such as more resilient new variants. A recent empirical study of actual vaccination rates using data on 32 countries in Europe and including Israel revealed a 72 percent effectiveness of vaccination against deaths.
Yet even for well-vaccinated countries like Singapore, there are still risks. The emerging science suggests that herd immunity – in the sense that most of the population achieves immunity against infectious disease, in this case COVID-19 – may need to be re-thought for various reasons. These include the uneven vaccine roll-out across countries, the lack of certainty on whether vaccines prevent transmission, the impermanence of immunity (and the need for boosters), and most of all, the emergence of new variants, some of which may even prove resilient to present vaccines.
At least one study of 50,000 patients in the Mayo Clinic Health System in the United States found evidence that the effectiveness of the Moderna vaccine against infection from the more virulent Delta variant dropped from 86 percent to 76 percent, while the effectiveness of the Pfizer-BioNTech vaccine against the same variant dipped from 76 percent to 42 percent. A growing number of medical experts believe booster shots are likely necessary because of this emerging evidence.
In the Philippines, the situation is far from Singapore’s. As of September, vaccination was only at roughly 20 percent (as opposed to Singapore’s over 80 percent), slowed by delivery delays and vaccine hesitancy. Furthermore, containment in the Philippines is weak and the country has been pushed into hard lockdown at least four times during the pandemic. It holds the dubious distinction of having implemented the longest general lockdown in the world and is one of only five countries that have kept their schools closed for well over one year of pandemic. As a result, the Philippines has been ranked in the bottom of pandemic resilience measures by Bloomberg (53rd of 53 countries) and Nikkei Asia (121st of 121 countries). Oxford Economics also ranked the Philippines last in Asia in terms economic scarring from the pandemic, signaling a protracted recovery period.
The country seems to have little choice but to open up an already flagging economy. From one of the fastest growing economies in Asia prior to the pandemic, the Philippines suffered one of the worst economic contractions in 2020, and the government forecasts it will take at least a decade to recover from the economic effects of its poor pandemic management.
The Economics of Living With COVID-19
Countries with already high vaccination rates like Singapore face diminishing returns to further intensified mobility restrictions. As one drives the number of cases closer to zero, the economic costs due to these restrictions probably begin to outweigh the marginal benefit of continuing to reduce cases, especially at low COVID-19 levels. The balance on the margin will continue to shift in favor of pursuing openness and tolerating a non-zero case total, as vaccination coverage continues to improve and hospitalization (and mortality) rates start to decline. In this “new normal” policymakers will likely emphasize monitoring hospitalization and mortality rates. Infection rates will still need monitoring, but it will be crucial to reassure the public that most will be able to recover quickly due to vaccination.
If we draw on the emerging evidence on vaccination in other countries, there can be up to 72 percent reduction in mortality from mass vaccination, and with more countries achieving higher vaccination rates, this could lead to mortality figures that begin to approximate those of other diseases like pneumonia. Particularly vulnerable groups like the elderly and those with comorbidities will still need additional precautions, but the rest of the population can begin to regain a semblance of normality.
On the opposite side of the spectrum from Singapore, the case for living with COVID-19 will also intensify in countries like the Philippines that are already paying a high economic price due to lockdowns that choke economic growth, intensify unemployment, and ratchet up poverty now that the pandemic is nearing its second year. However, due to less effective pandemic management, the trade off on the margin is likely to be brutal in terms of lives lost.
A recent World Bank study found evidence that a lockdown in a low-income country could potentially lead to almost two children’s lives lost due to the economic contraction caused by that lockdown for every COVID-19 fatality that the same lockdown prevents. Lower middle-income countries have an average ratio of 0.59 while high-income countries have an average ratio of 0.06. These figures suggest that lockdowns in poorer countries could potentially increase net deaths rather than diminish them, primarily because of the economic harm.
Clearly, the end goal is to strike a balance by bringing back openness and a semblance of normalcy, while maintaining agile containment systems to keep case levels manageable. There are still many unknowns but there is general agreement that expedited and inclusive vaccination is key. Laggards like the Philippines need to close the gap with vaccination leaders like Singapore.
For the international community, it is imperative that strong vaccination coverage, particularly in countries that risk creating new variants, be supported. Vaccine supply and distribution issues need to be addressed immediately and with greater fairness and inclusion across countries. The growing traction of anti-vaxxers is feeding vaccine hesitancy in some countries, and this also needs to be addressed with urgency.